Early and late complications associated with transcatheter occlusion of secundum atrial septal defect

Global and regional left ventricular function in patients undergoing transcatheter closure of secundum atrial septal defect

This study sought to evaluate global and regional left ventricular (LV) function before and early after device closure of atrial septal defects (ASDs) in patients with normal pulmonary pressure. Global LV diastolic function was unaffected by ASD closure. An improvement in global LV systolic function at rest resulted in an increase in stroke volume at rest. Nevertheless, total cardiac output did not change after the procedure, because of a decrease in heart rate at rest counterbalancing the increase in stroke volume. Thus, lateral and inferior LV regional systolic function were preserved after device implantation. Moreover, no changes in regional LV diastolic function were highlighted during the study.

Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment

OBJECTIVE

To determine the feasibility and effectiveness of endoscopic atrial septal defect (ASD) closure when percutaneous ASD closure is impossible or has failed.

PATIENTS

Between March 1997 and February 2003, 74 patients (63% female, mean (SD) age 44 (16) years) underwent an endoscopic ASD closure. Median preoperative New York Heart Association functional class was I. Clinical and echocardiographic follow up was obtained for all patients (mean (SD) 38 (19) months). Patients were assessed for scar aesthetics, procedure related pain, functional recovery, and overall patient satisfaction.

RESULTS

ASD closure was successful in all patients (two primum ASD, 68 secundum ASD, four sinus venosus type). Patch repair was performed in 42%. Mean aortic cross clamp and cardiopulmonary bypass times were 54 (24) minutes and 98 (35) minutes, respectively. There were no in-hospital deaths and no conversions to sternotomy. Complications included one iliac vein stenting, one femoral arterioplasty, two revisions for suspected bleeding, and seven cases of atrial fibrillation. Two patients required late reoperation: one for atrial thrombus and another for tricuspid regurgitation. Echocardiographic control confirmed complete ASD closure in 71 patients and a small residual shunt in three patients. Ninety three per cent of the patients were highly satisfied with very low procedure related pain and 97% felt they had an aesthetically pleasing scar.

CONCLUSION

Endoscopic ASD closure can be safely done with a high degree of patient satisfaction. It is now the authors' exclusive surgical approach whenever percutaneous treatment is not indicated or has failed.

Embolization and transcatheter retrieval of coils and devices

Embolizations of coils and devices are well-known complications of transcatheter procedures performed in order to occlude extracardiac or intracardiac shunts. A review of the literature and of our experience was performed to provide a succinct review of existing transcatheter retrieval techniques. After embolization of a coil or device, the appropriate initial procedure involves repositioning of the coil or device using a snare or bioptome to a location where harm to the patient is minimized. The subsequent retrieval technique depends on the characteristics of the coil or device involved. Coils may be retrieved using a bioptome or a snare. Devices must be snared, often in specific places. Both may be pulled into long or short, appropriately sized retrieval sheaths. To minimize potential morbidities associated with these retrievals and to maximize efficacy of retrieval, operators performing transcatheter coil or device occlusions must be familiar with retrieval techniques.

Long-term outcome of transcatheter secundum-type atrial septal defect closure using Amplatzer septal occluders

OBJECTIVES

The aim of this study was to assess long-term results of percutaneous closure of secundum-type atrial septal defect (ASD II) using Amplatzer septal occluders (ASO).

BACKGROUND

Only immediate-, short-, and intermediate-term results of ASO implantation are known so far.

METHODS

Between September 1995 and January 2000, 151 patients underwent a successful percutaneous closure of ASD II in our institution. All were included in the present study and were followed up until September 2004.

RESULTS

This group of patients was followed up from 56 to 108 months (median 78 months). The mean stretched defect diameter was 15.9 +/- 4.8 mm. There were no deaths or significant complications during the study. At three years of follow-up, all defects were completely closed and remained closed thereafter.

CONCLUSIONS

Since the first human implantations in September 1995, the Amplatzer septal occluder proved as a safe and effective device for percutaneous closure of ASD II.

Challenges encountered during closure of atrial septal defects

Since the introduction of transcatheter interventional occlusion of atrial septal defects (ASDs) by King and coworkers, the device closure has become the standard treatment of selected atrial defects. Although it has become routine for standard clinical practice, increasing knowledge of intracardiac anatomy, modification of implantation techniques, and improvements in device designs are making this treatment modality increasingly applicable to a wider range of selected patients. This report summarizes the current trends in patient selection, focusing on the anatomical limits of applicability for ASD device closure, and discusses the future possibilities. Furthermore, typical complications are described with regard to the rare erosion of the atrial roof or the aortic root. Current practice is to oversize the device if the anterior rim toward the aorta tends to be diminutive, achieving a secure position of the device around the aortic root. This and the shape memory of the device may play a major role in this serious complication and should be reconsidered. Although most interventional occlusions of interatrial defects with a device have become clinically routine, some situations remain highly challenging.

Echocardiographic guidance of transcatheter closure of atrial septal defects: is intracardiac echocardiography better than transesophageal echocardiography?

Transcatheter closure of atrial septal defects is an established practice. The imaging method best suited for guidance of this procedure is under debate. This review highlights the areas of disagreement and presents available evidence supporting the contention that intracardiac echocardiography is at least as good, if not a superior imaging method to guide the procedure. Points of discussion include comparisons of imaging capability, complications or discomfort, and the relative costs of these procedures. It is concluded that intracardiac echocardiography is the superior imaging method.

Electron beam angiography for the evaluation of percutaneous atrial septal defect closure

Electron beam angiography (EBA) provides excellent anatomic imaging in patients with congenital heart disease and may be useful in the assessment of atrial septal defects (ASDs). We present four patients with an ASD who were considered for percutaneous closure and underwent EBA for measurement of defect size and assessment of rim adequacy, adjacent cardiac structures, and associated congenital anomalies.

Two cases of late embolization of Amplatzer septal occluder devices to the pulmonary artery following closure of secundum atrial septal defects

The Amplatzer septal occluder (ASO; AGA Medical Corporation) is a self-expanding nitinol double-disk device that is being used for atrial septal defect closure with increasing frequency. The morbidity of the procedure is thought to be low, but complications are possible. We describe two cases of delayed embolization of the device to the right heart. Our patients both required surgical retrieval of the devices, which had migrated to the pulmonary artery.

Closure of a moderately large atrial septal defect with a self-fabricated fenestrated Amplatzer septal occluder in an 85-year-old patient with reduced diastolic elasticity of the left ventricle

Percutaneous closure of an atrial septal defect (ASD) in the elderly with reduced diastolic elasticity of the left ventricle poses a significant management challenge. We report on the case of an 85-year-old patient who was admitted for percutaneous device closure of a moderately large secundum atrial septal defect. Hemodynamic evaluation documented an increase in left atrial pressure from a mean of 12 mm Hg to a mean of 32 mm Hg after balloon test occlusion of the ASD. Two months later, after adequate pretreatment with diuretics and afterload-reducing substances, he underwent successful closure of the ASD using a self-fabricated fenestrated Amplatzer septal occluder, which resulted in a postimplantation left atrial pressure of a mean of 18 mm Hg. Recovery was unremarkable and the fenestration has remained patent for 3 months since implantation of the device. This unique case highlights the feasibility of using a self-fabricated fenestrated Amplatzer septal occluder to close interatrial communications in elderly patients with diastolic dysfunction of the left ventricle.

Amplatzer atrial septal defect occluder for pediatric patients: radiographic appearance

PURPOSE

To describe the chest radiographic appearance of the Amplatzer septal occluder (ASO) (AGA Medical Corporation, Golden Valley, Minn) for atrial septal defects (ASDs) in pediatric patients.

MATERIALS AND METHODS

Two radiologists independently reviewed frontal and lateral chest radiographs obtained in young patients 24 hours after transcatheter ASD closure with the ASO. The appearance (flat disks or dots) and location of the ASO were recorded. The location was related to that of a thoracic vertebral body on frontal and lateral chest radiographs and to a line drawn between the anterior margin of the right hilum and the posterior margin of the inferior vena cava (hilar-caval line) on lateral radiographs; this line corresponded to the expected position of the interatrial septum. The relationship between ASO appearance and patient age was assessed with logistic regression and cumulative probability plots.

RESULTS

Sixty-eight pediatric patients (age range, 1 month to 18 years; mean age, 4.2 years; 24 boys and 44 girls) were included. On frontal radiographs, the ASO center projected between T7 and T9, either to the right of or over the spinous processes of the vertebral body. On lateral radiographs, the ASO projected over (n = 66) or anterior to (n = 2) the hilar-caval line. On frontal radiographs, it appeared as one or two flat disks (n = 61) or as two metallic dots (n = 7). On lateral radiographs, it appeared as two flat disks (n = 54) or as two metallic dots (n = 14). The relationship between increasing patient age and the metallic dot appearance on frontal and lateral radiographs and on the combination of frontal and lateral radiographs was highly significant in each case (P < .001, likelihood ratio chi(2) test), with r(2) values of 0.35, 0.20, and 0.28, respectively. ASDs were successfully occluded with the ASO in all patients except one, in whom trivial shunting was seen at 12-month follow-up.

CONCLUSION

The ASO in pediatric patients has a characteristic radiographic appearance when properly positioned.

Embolization and retrieval of the Amplatzer septal occluder

Embolization and percutaneous retrieval of the Amplatzer septal occluder (ASO) after release have been reported. However, the incidence, the causes of embolization, and the methods for effective retrieval have not been systematically described. In a survey of the ASO company-designated proctors, the incidence of ASO embolization in this group's experience was 0.55% (21 embolizations in 3824 device placements) with a wide range of patient demographics, atrial septal defect (ASD) sizes, and device sizes. Most embolizations occurred because of inadequate rim or undersized devices. Of the 21 embolizations, 15 of the devices were retrieved percutaneously with a gooseneck snare without morbidity or mortality. Six were retrieved at surgery. Of the 21 patients, 12 had ASO closure of their ASDs, and 9 had surgical ASD closure. In vitro, all devices could be retrieved with sheathes 2 Fr sizes larger than their recommended delivery sheath. Any device larger than 26 mm could be retrieved with its delivery sheath. The ability to pull the snared button into a sheath was variable and was assisted by pulling the device from above with a bioptome and by using a rigid notched sheath. Because the incidence of ASO embolization is about 1 in 200 in the most experienced hands, all operators should be prepared with the techniques and equipment required for percutaneous ASO retrieval.

Infective endocarditis after transcatheter closure of a patent foramen ovale

Infection of devices for percutaneous transcatheter closure of atrial septal defects are exceedingly rare. Two cases of device-associated endocarditis have been reported, which were both operated on. We describe the successful treatment with antibiotics of a device-associated endocarditis.

Amplatzer septal occluder closure of secundum atrial septal defects in the presence of persistent left superior vena cava to coronary sinus

Secundum atrial septal defects (ASDs) are routinely closed using transcatheter devices. In patients with left superior vena cava (LSVC) draining to the coronary sinus (CS), the device must not obstruct CS drainage. We report five cases of successful ASD device closure without obstructing flow from the LSVC or dilated CS.

Closure of defects of the atrial septum in adults using the Amplatzer device: 100 consecutive patients in a single center

BACKGROUND

Transcatheter device closure of atrial septal defects (ASD) is an alternative to surgery, but experience is limited in adults, especially in those with large (> 26 mm) defects.

HYPOTHESIS

We investigated the safety, efficacy, and learning curve for closure of ASD and patent foramen ovale (PFO) using the Amplatzer device.

METHODS

In all, 101 procedures were carried out in 100 consecutive adult patients in a single cardiac center between July 1998 and August 2002.

RESULTS

Preprocedure diagnosis was ASD and PFO in 50 patients each. A device was deployed in 94 of 101 attempts (93%) in 94 of 100 patients (94%). Atrial septal defect device sizes were 10-38 mm, median 24 mm, and 40% were > 26 mm. Major complications occurred in 2 of 100 patients (2%). One ASD device displaced requiring surgery within 24 h and one patient with PFO experienced pericardial tamponade; there were no deaths. Local vascular complications occurred in 4 of 100 (4%) and late complications in 4 of 100 (4%) patients. Patent foramen ovale closure was quicker (p<0.001), required less radiation (p=0.04), and was associated with fewer local vascular complications than ASD closure (p=0.04). Deployment of ASD devices > 26 mm was not associated with increased complications, length of procedure, or radiation compared with devices < or = 26 mm (all p>0.05). Complications in the first 35 patients were more frequent than in subsequent patients: 7 of 35 (20%) versus 3 of 65 (4.6%) (p=0.04); procedure and fluoroscopy times (both p<0.001) and radiation doses (p=0.001) were also higher.

CONCLUSION

The Amplatzer device is an effective method for transcatheter closure of interatrial defects in adults, including large ASDs up to 38 mm. Major complications are uncommon. A learning curve of approximately 35 cases was suggested by the decline of complications, procedure times, and radiation exposure.

Symptomatic atrial arrhythmias and transcatheter closure of atrial septal defects in adult patients

OBJECTIVE

To determine whether transcatheter device closure of a secundum atrial septal defect (ASD) will reduce the risk of developing subsequent atrial arrhythmias.

DESIGN

The incidence and predictors of symptomatic atrial tachyarrhythmias (AT) were examined in adults undergoing transcatheter closure of ASDs.

SETTING

Toronto Congenital Cardiac Centre for Adults.

PATIENTS

132 consecutive patients, mean (SD) age 44 (16) years; 74% female.

MAIN OUTCOME MEASURE

Sustained or symptomatic atrial arrhythmias at early follow up (six weeks; n = 115) and intermediate follow up (last clinic visit 17 (11) months post surgery; n = 121).

RESULTS

15% of the patients (20 of 132) had AT before the procedure (14 paroxysmal, six persistent). Patients without a history of arrhythmia had a low incidence of AT during early follow up (6%) and intermediate follow up (1%/year), while all patients with persistent AT before closure remained in atrial fibrillation or flutter. Of patients in sinus rhythm but with a previous history of AT, two thirds remained arrhythmia-free at follow up, with overall incidences of paroxysmal and persistent AT of 17%/year and 11%/year. A history of AT before closure (risk ratio (RR) 35.0, 95% confidence interval (CI) 7.2 to 169.0) and age > or = 55 years at the time of device insertion (RR 5.6, 95% CI 1.2 to 25.0) predicted AT after closure.

CONCLUSIONS

Device closure of an ASD before the onset of atrial arrhythmias may protect against the subsequent development of arrhythmia, in particular in patients less than 55 years of age.

Transcatheter closure of intracardiac shunts

Intracardiac shunts, such as atrial septal defects (ASDs), patent foramen ovales (PFOs), and ventricular septal defects (VSDs), are common forms of congenital or acquired heart disease. Traditional treatment has consisted of surgical closure. Transcatheter closure using implantable devices is now an alternative approach to the treatment of these lesions. Transcatheter closure offers advantages over surgical closure: 1) it is less invasive, resulting in shorter recovery times, less hospital time, and no scarring; 2) it avoids the deleterious neurocognitive effects of cardiopulmonary bypass; 3) it avoids the proarrhythmic effects of atrial or ventricular incisions; and 4) it is potentially less costly. Device closure of secundum ASDs is the procedure of choice. Device closure of PFOs can be performed under humanitarian device exemption (HDE) guidelines, although the indications for this procedure and its effectiveness compared with medical management remain controversial. Ongoing studies are addressing these issues. Transcatheter closure of muscular VSDs is an alternative to surgical treatment, especially for apical defects or those anterior to the moderator band. The CardioSEAL device (NMT Medical, Boston, MA) has HDE status for this purpose and the Amplatzer muscular VSD device (AGA Medical Corp., Golden Valley, MN) is being reviewed by the US Food and Drug Administration for market approval. Phase 1 investigations are underway for device closure of perimembranous VSDs using the Amplatzer perimembranous VSD device (AGA Medical Corp.). Until more data are available, surgical closure of perimembranous VSDs is still the procedure of choice. Closure of postinfarct VSDs can also be accomplished using intracardiac devices; however, this remains a high-risk procedure. Early experience compares favorably with surgical closure. Transcatheter device closure of intracardiac defects is a relatively new procedure. Long-term data for these procedures are currently lacking and, therefore, recommendations regarding the use of these devices will continue to evolve with time.

CardioSEAL/STARflex versus Amplatzer devices for percutaneous closure of small to moderate (up to 18 mm) atrial septal defects

BACKGROUND

The Amplatzer septal occluder (ASO) allows the percutaneous closure of small to very large atrial septal defects (ASDs). The CardioSEAL/STARflex (CS/SF) can be used only for closure of small to moderate ASDs (stretch size up to 18 mm). These 2 devices are widely used in clinical practice. Therefore, a comparison of their use in the closure of small to moderate ASDs is needed.

METHODS

From December 1996 to September 2002, 274 consecutive patients (mean age 20.3 +/- 17 years) underwent percutaneous closure of small to moderate ostium secundum ASDs. The CS/SF device was used in 121 patients, and the ASO was used in 153.

RESULTS

There were no differences in age, sex ratio, or pulmonary/systemic flow ratio. Stretch size of the defect was higher in the ASO group (13.6 +/- 3.5 mm vs 15.5 +/- 3.2 mm, P <.001). Procedure time and fluoroscopy time were shorter in patients treated with the ASO (61 +/- 21 vs 75 +/- 32 min, P <.0003, and 11.6 +/- 9 vs 23.8 +/- 17.4 min, P <.0001, respectively). Residual shunt at procedure and discharge was significantly more frequent in the CS/SF group (P <.0001). There were no differences in the complication rate for the 2 groups (CS/SF 4/121 vs ASO 6/153). Length of follow-up was longer in the CS/SF group (24 +/- 14 vs 16 +/- 9 months, P =.0001). Residual shunting was significantly more frequent in the CS/SF group during follow-up, while closure rate reached 100% after 1 month in ASO group.

CONCLUSIONS

The 2 devices are clinically safe and effective in ASD closure. However, percutaneous closure of small to moderate ASDs with ASO is quicker and provides an higher rate of complete occlusion.

Short- and intermediate-term results of transcatheter closure of atrial septal defect with the Amplatzer Septal Occluder

BACKGROUND

The Amplatzer Septal Occluder (ASO) (AGA Medical Corp, Golden Valley, Minn) has gained wide acceptance for transcatheter closure of atrial septal defect (ASD). We conducted this study to evaluate the short-and intermediate-term results of ASD closure with the ASO and to determine the impact of deficient rim on the results.

METHODS

Between March 1999 and February 2003, 197 patients underwent attempted transcatheter closure of ASD with the ASO. The size of the selected device either equaled or was 1 to 2 mm larger than the stretched diameter of the defect. Transesophageal echocardiography was used to monitor the implantation procedure. One hundred and fourteen patients (58%) with a deficiency in 1 rim (<5 mm) were included as group I, and the remaining 83 patients with adequate rims comprised group II.

RESULTS

The mean stretched diameter measured with the balloon catheter was 18.6 +/- 6.7 mm (range 7.1-37.2 mm). Deployment of the ASO was successful in 191 (97%) patients and failed in 6. There was no significant difference between the 2 groups in the success rate for ASD closure (110/114 vs 81/83). Repositioning of the device was required in 28 patients: 21 in group I and 7 in group II (21/114 vs 7/83, P >.05) The mean stretched diameter of the defect in these 28 patients was significantly larger than that in those who did not require repositioning of the device (27.3 +/- 5.7 vs 17.1 +/- 5.5 mm, P <.01). Three patients experienced severe complications: 1 had transient complete atrioventricular block, 1 had tamponade requiring drainage, and 1 had dislodgement of the device requiring emergent operation. One had a distal embolism to a fingertip. Echocardiography at 1 day, 3 months, 6 months, 12 months, and 24 months after the procedure showed residual shunts in 37/191 (19%), 15/189 (8%), 11/176 (6%), 7/131 (5%), and 3/72 (4%) patients, respectively.

CONCLUSIONS

The ASO is a safe and effective device for the transcatheter closure of ASD. Deficiency in 1 rim, particularly the superior anterior rim, does not influence the success rate of ASD closure.

Transthoracic echocardiographic guidance of transcatheter atrial septal defect closure

This study examines the safety and efficacy of transthoracic echocardiographic (TTE) guidance of atrial septal defect (ASD) device closure. We evaluated 74 patients for TTE-guided ASD closure. Fifty-six patients had successful device implantation using TTE guidance. Twelve patients were referred for surgical ASD closure on the basis of TTE evaluation. Five patients with multiple ASDs or poor transthoracic acoustic windows had ASD device closure guided by transesophageal echocardiography (TEE).

Reversible atrioventricular block associated with closure of atrial septal defects using the Amplatzer device

OBJECTIVES

We sought to determine the incidence, nature, and predisposing factors of atrioventricular block (AVB) associated with closure of atrial septal defects (ASDs) using the Amplatzer septal occluder (ASO).

BACKGROUND

In our institution, 162 patients underwent ASD closure using ASO between December 1997 and December 2001. This includes small children with large defects.

METHODS

Electrocardiographic tracings during ASO implantation and at follow-up visits were reviewed. Anatomic characteristics and device size were assessed as potential risk factors for AVB.

RESULTS

Ten patients (6.2%) presented with new-onset (n = 9) or aggravation of preexisting (n = 1) AVB. Atrioventricular block occurred during the procedure (n = 3) or was first noted one day to one week later (n = 7). Patients had first-degree (n = 4), second-degree Wenckebach (n = 4), or third-degree (n = 2) AVB, with no symptoms or hemodynamic compromise. First-degree AVB persisted in two patients at 12 and 33 months of follow-up, whereas most recovered normal AV conduction within one (n = 7) or six months (n = 1). A larger shunt (Qp/Qs ratio 2.8 +/- 0.9 vs. 2.1 +/- 0.8, p < 0.01) and device size (24 +/- 5 vs. 19 +/- 6 mm, p < 0.01) were the only determinant factors for AVB. A device size > or =19 mm was used in 90% (9 of 10) of patients who developed AVB, as compared with 49% of those without AVB (p < 0.02).

CONCLUSIONS

Closure of ASDs using the large ASO can be associated with the development of AV block and mandate a closer follow-up. In our series, however, all AVBs resolved or improved spontaneously, with no recurrence at mid-term follow-up.

Successful treatment of left atrial disk thrombus on an Amplatzer atrial septal defect occluder with abciximab and heparin

Acute device thrombosis is a rare but important complication after transcatheter atrial septal defect closure. In this case a mobile thrombus was noted on the left side of an Amplatzer atrial septal occluder after device release in a 12 year old boy with an uncomplicated atrial septal defect. The thrombus was successfully treated with an infusion of heparin and the glycoprotein IIa/IIIb receptor antagonist abciximab. Transoesophageal ultrasound performed the following day showed complete resolution of the clot. There are no reports to guide treatment of acute thrombosis in this setting. This combination of treatments was effective without complication in this case.

Late cardiac perforation following transcatheter atrial septal defect closure

Transcatheter closure of secundum atrial septal defect (ASD) has become an alternative to surgery. We present a patient with hemodynamic collapse secondary to cardiac perforation occurring 6-months after the placement of an Amplatzer Septal Occluder and discuss the utilization/complications of this device.

Incidence and clinical course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients

OBJECTIVES

The purpose of this study was to investigate the incidence, morphology, and clinical course of thrombus formation after catheter closure of intra-atrial shunts.

BACKGROUND

Post-procedure detailed information about thrombotic material on different devices for transcatheter closure is missing.

METHOD

A total of 1,000 consecutive patients were investigated after patent foramen ovale (PFO) (n = 593) or atrial septal defect (ASD) (n = 407) closure. Transesophageal echocardiography (TEE) was scheduled after four weeks and six months. Additional TEEs were performed as clinically indicated.

RESULTS

Thrombus formation in the left atrium (n = 11), right atrium (n = 6), or both (n = 3) was found in 5 of the 407 (1.2%) ASD patients and in 15 of the 593 (2.5%) PFO patients (p = NS). The thrombus was diagnosed in 14 of 20 patients after four weeks and in 6 of 20 patients later on. The incidence was: 7.1% in the CardioSEAL device (NMT Medical, Boston, Massachusetts); 5.7% in the StarFLEX device (NMT Medical); 6.6% in the PFO-Star device (Applied Biometrics Inc., Burnsville, Minnesota); 3.6% in the ASDOS device (Dr. Ing, Osypka Corp., Grenzach-Wyhlen, Germany); 0.8% in the Helex device (W.L. Gore and Associates, Flagstaff, Arizona); and 0% in the Amplatzer device (AGA Medical Corp., Golden Valley, Minnesota). The difference between the Amplatzer device on one hand and the CardioSEAL device, the StarFLEX device, and the PFO-Star device on the other hand was significant (p < 0.05). A pre-thrombotic disorder as a possible cause of the thrombus was found in two PFO patients. Post-procedure atrial fibrillation (n = 4) and persistent atrial septal aneurysm (n = 4) had been found as significant predictors for thrombus formation (p < 0.05). In 17 of the 20 patients, the thrombus resolved under anticoagulation therapy with heparin or warfarin. In three patients, the thrombus was removed surgically.

CONCLUSIONS

The incidence of thrombus formation on closure devices is low. The thrombus usually resolves under anticoagulation therapy.

Incidence of thrombus formation on the CardioSEAL and the Amplatzer interatrial closure devices

Transcatheter closure for atrial septal defect (ASD) and patent foramen ovale (PFO) is a promising alternative to surgical closure or anticoagulant therapy. A potential complication is thrombus formation on the device after implantation. From February 2001 to June 2003, 66 patients with atrial communication were treated successfully with the Amplatzer device (16 septal and 20 PFO occluders) or the CardioSEAL device (30). Patients were discharged on antiplatelet medication (aspirin and clopidogrel) and/or anticoagulation. Fifty patients (76%) had transesophageal echocardiography (TEE) 1 month after device implantation (28 +/- 10 days). No patient experienced a thromboembolic episode during follow-up. TEE revealed that thrombus formation occurred more frequently on the CardioSEAL device (5 of 23 patients; 22%) than on the Amplatzer device (0 of 27 patients; 0%) (p = 0.02). Although thrombus disappeared or markedly diminished after additional anticoagulation therapy in 3 patients, 1 patient had surgical explantation of the device due to progressive increase in the size of thrombus with hypermobility despite intensive anticoagulation therapy. There was no variable associated with the presence of thrombus formation on the occluder other than the use of the CardioSEAL device. One month after insertion, the CardioSEAL device is more likely to have thrombus present than the Amplatzer device.

Five-year clinical and echocardiographic evaluation of the Das AngelWings atrial septal occluder

BACKGROUND

The late outcome of patients treated with atrial septal occluder devices remains incompletely defined. The purpose of this study was to assess the late outcome (range 4-7 years postprocedure) of patients in whom the Das AngelWings septal occluder device was implanted in the atrial septum. We report the clinical and echocardiographic outcome, at an average of 5 years following the procedure, of patients treated with the Das AngelWings device used to close either a secundum atrial septal defect (ASD) or a patent foramen ovale (PFO).

METHODS

Thirty-two patients underwent successful percutaneous closure of an atrial septal closure, patent foramen ovale, or fenestration in the lateral tunnel of their Fontan with the Das AngelWings device between June 1995 and March 1998 at Duke University Medical Center. Two of the 32 patients were lost to follow-up. The remaining 30 patients were divided into 3 groups based on indication for device implantation. Group 1 consisted of 14 patients with a secundum ASD and predominantly left-to-right atrial shunting. Group 2 consisted of 8 patients who had a PFO and who suffered a thromboembolic event. Group 3 (compassionate use) consisted of 10 patients with multiple comorbid medical problems with predominantly right-to-left shunting at the atrial level causing hypoxemia. Eight of the patients in group 3 were severely ill at the time of device implantation. The 2 remaining patients in group 3 underwent AngelWings implantation for closure of right-to-left shunting through a Fontan fenestration. Mean follow-up was 59 months.

RESULTS

There was no device embolization. No patient in the ASD or PFO/stroke group had a clinical complication. By radiographic examination, 2 of 27 patients had evidence of fracture of the nitinol framework at 2-year follow-up. Residual shunting was present in 44% at 24 hours, 20% at 1 year, and 18.8% at 2 years by use of Doppler color flow imaging and/or microcavitation echocardiographic studies. Mild mitral regurgitation caused by the AngelWings device occurred in 1 patient. One patient in the compassionate use group had a subsequent neurologic event. Five of the 10 patients in the compassionate use group died of comorbid illnesses in follow-up, none directly related to device complications.

CONCLUSION

The late clinical outcome of secundum ASD and PFO/stroke patients in this study demonstrates that Das AngelWings closure of the atrial septum is effective and safe. These data are encouraging with respect to the expanding use of other percutaneously implanted ASD occlusion devices, although late clinical safety and efficacy data are needed for the specific devices being implanted.

Absent posteroinferior and anterosuperior atrial septal defect rims: factors affecting nonsurgical closure of large secundum defects using the amplatzer occluder

Using transesophageal echocardiography, we sought to determine the anatomic characteristics of the secundum atrial septal defects (ASDs) that extend into the inferior sinus venosus and have no posteroinferior (PI) rim, to determine the factors related to potential closure with an Amplatzer occluder. We also sought to understand why large secundum ASDs with a PI but without an anterosuperior (AS) rim may require special techniques to reorient the left atrial disk before deployment of the waist and right atrial disk. We measured the lengths of 5 separate rims of the circumferences of 76 secundum ASDs, including anteroinferior, AS, superior, posterosuperior, and PI rims. We also measured anteroposterior and superoinferior defect diameters, total septal lengths, and the ratios of defect diameter to total septal length. The atrial depth was measured at the axial angle of the delivery sheath in 5 defects with no AS rim for which special techniques were required to achieve successful closure. Of 76 secundum ASDs, 13 (17%) had no PI rim. Each defect extended from the fossa ovalis into the inferior sinus venosus. Compared with defects with a PI rim, the factors related to potential closure included 100% larger defect diameters, shorter posterosuperior rim lengths, larger defect to total septal length ratios, and completely flat posterior atrial walls. When the AS rim was absent the factors related to the need for special techniques included diameters >/= 22 mm, atrial depth < the calculated Amplatzer occluder left atrial disk diameter, rigid wire/disk interface, and obligatory left atrial disk orientation more or less perpendicular to the atrial septal plane.

New technique for device closure of large atrial septal defects

The objective of this study was to describe a new technique for transcatheter device closure of large atrial septal defects (ASDs) using the Amplatzer septal occluder and our experience with this technique in 14 patients. Transcatheter closure of large (> 25 mm) ASDs is challenging. We have developed a balloon-assisted technique (BAT) to facilitate device closure of large ASDs. The BAT consists of using a balloon catheter to support the left atrial (LA) disk of the Amplatzer septal occluder during device deployment. The balloon support prevents prolapse of the LA disk into the right atrium. Between April 2003 and February 2004, 14 patients with large ASDs (mean age, 25.71 +/- 15.71 years; mean weight, 51.21 +/- 23.78 kg) underwent device closure with the Amplatzer septal occluder using the BAT. The median balloon-stretched diameter of the ASD was 32 (range, 26-40) mm. The median device size used was 33 mm (range, 26-40 mm). All 14 patients had successful deployment of the device using the BAT. The mean follow-up period was 16.5 +/- 11.95 weeks. No major complications were noted during the procedure or on short-term follow-up. The BAT enables predictably successful closure of large ASDs using the Amplatzer septal occluder.

Outcomes and alternative techniques for device closure of the large secundum atrial septal defect

Outcomes of device closure of large and small secundum atrial septal defects (ASDs) as related to rim anatomy with the Amplatzer atrial septal occluder were compared. Rim adequacy (> or = 5mm) of the anterior, inferior, posterior, and superior rims was determined using transesophageal echocardiography. Balloon-stretched defect size defined patients into two groups: group 1, < or = 25 mm (n = 138); group 2, > 25 mm (n = 34). Rim deficiency (n = 62) was more frequent in group 2 compared to group 1 (50% vs. 33%; P = 0.07), especially inferior rim deficiency (35% vs. 2%; P = 0.005). Device deployment was successful in group 1 and group 2 (100% vs. 91%; P = 0.007). Unsuccessful deployment was associated with an ASD of > 25 mm (P = 0.007) and inferior rim deficiency (P = 0.001). At first follow-up (54 +/- 16 days), right ventricular systolic pressure had improved in both groups (P < 0.001). Closure of a large ASD associated with a lack of support in the inferior rim may warrant alternative strategies to position the device successfully.

Migraine with aura related to the percutaneous closure of an atrial septal defect

We report a case of a 31-year-old woman who presented migraine attacks with aura within the 48 hr after transcatheter closure of an atrial septal defect with the Amplatzer septal occluder device. The migraine attacks persisted for 3 months, and all examinations performed to rule out a thromboembolic origin of migraine were negative.

Transcatheter closure of very large (>or= 25 mm) atrial septal defects using the Amplatzer septal occluder

Between June 1999 and September 2002, 45 patients (age, 34 +/- 13 years; mean shunt ratio, 2.6 +/- 0.6) underwent transcatheter atrial septal defect (ASD) closure at our institution with the Amplatzer septal occluder (mean device size, 31.4 +/- 3 mm). Patients were selected by transesophageal echocardiography. The mean ASD dimension was 25.3 +/- 3.7 mm and 33 (73%) patients had deficient anterior rim. Specific procedural details included the use of 13 or 14 Fr introducer sheaths and the right upper pulmonary vein approach if the conventional approach failed. There were two procedural failures, with device embolization in both (surgical retrieval in one, catheter retrieval in one). During follow-up (3-30 months; median, 16 months), one patient (59 years) with previous atrial flutter had pulmonary embolism and was managed with anticoagulation. Two patients developed symptomatic atrial flutter. Fluoroscopy time was 31.6 +/- 19.5 min for the first 22 cases and 19.6 +/- 11.4 min for the rest (P = 0.04). Transcatheter closure of large ASDs is technically feasible but careful long-term follow-up is needed to document its safety.

Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis

A 53-year-old man with a history of repair of atrial septal defect 3-months ago by primary suture was admitted to an emergency department with sudden onset chest pain and dyspnea. Transthoracic echocardiography revealed a large and mobile thrombus attached to the right side of the interatrial septum. The chest X ray and perfusion lung scan established the diagnosis of the multiple pulmonary emboli. Doppler examination of the venous system for a possible source of thrombus was unremarkable. The postoperative early appearance of thrombus and multiple pulmonary emboli defects at lung scan supported that thrombus was originated from the primary suture site. Thrombolytic treatment achieved complete resolution of the thrombus both in the pulmonary artery and at the repaired septal defect site. The patient was placed on warfarin and thrombus was not detected by transesophageal echocardiography at the 9-month follow-up.

Transcatheter closure of atrial septal defect in young children: results and follow-up

OBJECTIVES

This study sought to analyze the safety, efficacy, and follow-up results of percutaneous closure of secundum atrial septal defect (ASD) in young children.

BACKGROUND

Results of ASD transcatheter closure in adults are widely reported but there are no large published series concerning young children.

METHODS

Between December 1996 and February 2002, 48 of 553 patients percutaneously treated at our institution were children age <or=5 years. Indications for closure were: elective closure in 32 patients; frequent respiratory infections in 8; failure to thrive in 2; liver transplantation in 5; and a fenestrated Fontan in 1. The procedure was carried out under general anesthesia with fluoroscopy and transesophageal control. Two different devices were used: 1) the CardioSEAL/StarFLEX (CS/SF) and 2) the Amplatzer septal occluder (ASO). Basal physical examinations and echocardiograms were performed prior to the procedure and at follow-ups (1, 6, and 12 months, and yearly thereafter).

RESULTS

The mean age at closure was 3.6 +/- 1.3 years. A CS/SF was used in 10 subjects; an ASO was used in 38 patients. No deaths or immediate major complications occurred. The total occlusion rate was 87% at procedure, rising to 94% at discharge. The mean follow-up was 18 +/- 14 months. No midterm major or minor complications occurred. The occlusion rate rose to 100% at 12 months of follow-up. Symptomatic patients improved significantly.

CONCLUSIONS

In the current era and in experienced hands, ASD closure can be performed safely and successfully, even in very young children.

Radiologic findings of 2 commonly used cardiac septal occluders with clinical correlation

Transcatheter closure of an atrial septal defect, patent foramen ovale, or post-myocardial infarction ventricular septal defect has become a safe and effective alternative to medical and surgical therapy. Although the use of transcatheter closure of septal defects is becoming increasingly more popular, there are few reports of the radiographic appearance of the closure devices. We report the chest radiographic findings in 36 patients after transcatheter closure of septal defects with Amplatzer or CardioSEAL occluders in an effort to aid radiologists in recognizing the appearances of these devices and enable them to confirm proper positioning.

Large left atrial thrombus formation despite warfarin therapy after device closure of a patent foramen ovale

Appropriate anticoagulation after transcatheter device placement is controversial. Patients with no history of thromboembolism or neurologic event typically receive antiplatelet therapy for several months while the device endothelializes. For patients with a history of stroke, there are no established guidelines for postdevice anticoagulation. Most patients receive warfarin, antiplatelet therapy, or a combination. Thrombus formation after transcatheter device placement has been reported for most commercially available devices. We describe a patient who developed a left atrial thrombus after closure of a patent foramen ovale with a CardioSEAL device. The patient had a normal hypercoaguable laboratory evaluation prior to device placement. Thrombosis occurred despite warfarin therapy before and after device placement. The patient's international normalized ratio was checked every 2 weeks after device placement and ranged between 2.0 and 2.8. She had no clinical arrhythmia during this time period. The left atrial thrombus was detected on routine follow-up transthoracic echocardiogram performed 6 months after device deployment. A subsequent transesophageal echocardiogram demonstrated no residual shunt, appropriate positioning of the device, flat against the septum, and a 1 x 2 cm thrombus attached to the superior and posterior left atrial arm near the junction with the native septum. A fluoroscopic image demonstrated no arm fractures. The device and thrombus were subsequently removed at surgery without complication. This case is perplexing in that the patient received appropriate anticoagulation had a negative hypercoaguable work-up, no residual shunt, and a well-positioned device.

Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications

BACKGROUND

This study sought to test whether intracardiac echocardiography (ICE) is superior to conventional monitoring in guiding device closure of interatrial communications (atrial septal defect [ASD] and patent foramen ovale [PFO]).

METHODS AND RESULTS

Forty-four patients undergoing device closure of ASD (n=6) or PFO (n=38) were randomized to have the procedure guided by either ICE (group 1; n=22) or by transesophageal echocardiography (TEE) (group 2; n=22). All interventions were completed successfully. In 1 patient from group 2, atrial fibrillation occurred 1 day after device implantation; the patient was successfully cardioverted on the next day. There were no other complications. Fluoroscopy time (FT) (6.0+/-1.7 minutes versus 9.5+/-1.6 minutes; P<0.0001) as well as procedure time (PT) (33.4+/-4.7 minutes versus 37.8+/-5.6 minutes; P<0.01) were shorter in group 1 than in group 2. Group 2 patients required general anesthesia without (n=19) or with endotracheal intubation (n=3). In contrast, ICE allowed continuous monitoring of the whole procedure, including balloon sizing before device closure, without sedation.

CONCLUSIONS

ICE is a safe tool to guide device closure of PFO and ASD. Supine patients tolerate ICE better than TEE. ICE reduces FT and PT. ICE seems to be advantageous, especially when long continuous or repeated echocardiographic viewing is required.

Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder

An aorta-to-right atrial fistula developed within 3 months after closure of an atrial septal defect using the Amplatzer septal occluder. Surgical correction was required. The cause of this complication appears to be erosion into the aorta by the right atrial disk.